Creating a new pediatric residency program is a daunting yet rewarding endeavor. There are many important decision points along the way, each with its own potential benefits and drawbacks. This chapter highlights many of the decisions and challenges faced during the development of a novel program or function as a guide for those responsible for the creation of future programs. Although the focus of this chapter is on a categorical pediatric residency program, many of the lessons learned are applicable to other residency and fellowship programs.